TherAplay uses horses for therapy
Two-and-a-half-year-old MaCayla Smith stands astride her horse like a tiny circus performer, dropping physical therapist Jen Grillo’s hand to wave at her parents and big brother. With Grillo firmly supporting MaCayla’s diaper-plump bottom and volunteer Peggy Cremer holding her other hand, the little girl jounces and jigs atop Percy the horse as he walks around the barn.
She rounds the corner and her parents, Bill and Cathy Smith, together with 5-year-old Jacob, call encouragement from behind a gate.
“She’s gotten so confident, can you believe that?” Grillo says to Cremer and horse handler Carol Shipley, who guides Percy from behind with long reins. “Remember the first time we put her on a horse, how she screamed?”
That first equine-assisted physical therapy session at Children’s TherAplay Foundation was just eight months ago. MaCayla, who has Down’s Syndrome, was not yet walking. Crawling and rolling were her chief tactics for mobility, and she used to scream in frustration when she wanted something she couldn’t reach.
Now MaCayla is finding her feet, and getting things for herself. In fact, she’s practically running, well before the age of 3 when most Down’s kids begin walking.
“She’s like a whole different kid,” Cathy Smith says. “She’s walking everywhere and climbing on everything.”
MaCayla’s weekly sessions at TherAplay, a pediatric physical therapy clinic that uses horses as therapeutic tools, have made a huge difference.
“They’ve been working on strengthening a lot of her torso muscles so she could stand and have stability. Now nothing is safe in my house. And that’s OK,” Smith says, laughing.
A furry, four-legged treatment tool
MaCayla Smith no longer interacts with the world as a helpless baby. She can scoot up and down stairs at a pretty fast clip, propel herself on a ride-along toy and walk down a sloping driveway with confidence.
TherAplay Executive Director Raquel Ravinet says the nonprofit outpatient rehab clinic, located in Carmel, does physical therapy and occupational therapy like any other clinic. “The only difference is we use a furry, four-legged treatment tool that most other clinics don’t,” she says.
Though termed hippotherapy, the treatment is actually just another way of providing physical and occupational therapies. The service is offered to children with both physical and mental disabilities. A physician’s prescription is required, and the sessions are conducted by a registered or licensed therapist, with the patient’s progress documented in accordance to state guidelines.
Since 2001, TherAplay has been seeing children like MaCayla, achieving some serious objectives in an environment unlike any other. Starting with two horses and two part-time therapists, back then the clinic saw 10 kids a week. Now they are up to eight horses, a barn staff of four and a therapeutic staff consisting of two physical therapists, two occupational therapists and one speech therapist.
Over 100 children, some as young as 18 months, come through the barn doors each week for hippotherapy. An additional 20 or so children come for adaptive riding classes. Some drive two and a half hours one way. “We are the only full-time clinic dedicated to horses in Central Indiana,” Ravinet says, adding that TherAplay is one of the largest clinics of its kind in the country.
Most of the therapists working there have at least a master’s degree, and all have had continuing education in the particular field of equine-assisted therapy. TherAplay regularly hosts American Hippotherapy Association educational seminars for professionals in the field. The courses cover horse anatomy, equine skills and treatment principles. Attendees learn to evaluate horses for their suitability for this work, and to assess the type of movements individual horses can produce in a client.
Ravinet notes that the treatment goes far beyond “putting a kid on a horse and hoping for something good to happen.” Horses are partnered with individual patients based on their size, gait patterns, speed and degree of lateral movement. Each session is carefully planned and charted, with the horse’s movements painstakingly calibrated to work toward specific therapeutic objectives. Stopping, starting, weaving, trotting: All have particular therapeutic effects.
Horse handlers like Carol Shipley play a vital role in getting the best out of each horse. Each handler has a minimum 10 years riding experience, and most of them also show horses. Their job in the TherAplay setting is to ensure that the horse’s movements are exactly what the therapist requires.
The four-legged members of the therapeutic team, without whom there would be no hippotherapy, are scrupulously screened and trained. All the horses are donated, and with TherAplay’s reputation for keeping their equine staff happy and healthy, there is never a shortage of candidates.
Before coming on board, each horse is profiled for a people-friendly, attention-hungry temperament. Ravinet notes that one horse, Gideon, came to TherAplay after he kept breaking out of his stall and heading a mile and a half up the road to hang out with some kids. A staff member who stabled her horse at the same facility finally asked, “Does Gideon need a job?”
During a trial period that may last up to 90 days, the staff works to acclimate the horse trainee to the unusual demands of the job. “They’ll yell, throw things, lean way over on the horse’s back and basically do anything they can think of that a kid would do,” Ravinet says. By the end of the trial period, horses that make the cut are integrated into the program.
Conventional tools complement hippotherapy
Jen Grillo eases MaCayla down to a seated position on Percy. She situates the child sideways on the horse, then asks, “Where’s your nose?” MaCayla mashes a pudgy hand to her nose, to the delight of the whole team. “Where’s mine?” She reaches for Grillo’s face. A high five prompts another reach, working her abdominal muscles as she keeps her balance. She maintains her posture well, held in place across the thighs by Grillo’s forearm.
TherAplay therapists walk an estimated 10 miles a day. For much of the time, they are turned sideways, arms upstretched to support the client. Because of these physical demands, the clinic sets an upper weight limit for patients. While a few adults are included in the program, none weigh more than 150 pounds. More typically, the patients start young, like MaCayla.
In addition to 30 minutes of hippotherapy, each hour-long session includes 30 minutes of therapy with traditional kid-friendly tools as well. In MaCayla’s case, today she has already worked on tasks like “pincher grasping” puzzle pieces while maintaining her balance on a peanut-shaped exercise ball. Grillo notes that the conventional clinic allows MaCayla to work on functional skills as well as more trunk strengthening.
The combined approach works well for another reason: For children with sensory integration problems, as in autism, bouncing astride a trotting horse is calming. Once they have had a half hour of this kind of organized, controlled movement, they can focus better cognitively and physically on the other skills.
Ravinet recalls an autistic child whose school was hesitant to allow him time away once a week for TherAplay. But after school officials noticed that the child was more manageable on the day following a hippotherapy session, they suggested twice weekly sessions.
Jackie Wrin, one of TherAplay’s occupational therapists, says this is because “riding a horse is very grounding.” If a child’s sensory needs are met in this way, she says, he is less likely to misbehave and more able to tend to a task.
Tara Sheringer of Brownsburg calls her daughter Julia a “sensory seeker.” Five-year-old Julia’s diagnosis is on the autism spectrum. Since starting at TherAplay about two years ago, she has made strides in all areas, from core strengthening to fine motor skills to the social realm — even improving her eye contact.
“The sensory input puts her body in a better place to learn all those skills,” Sheringer says. She calls hippotherapy “an overall body experience” that includes the side walker and therapist engaging Julia in conversation. “They ask her questions and she needs to respond back. She’s supposed to look at them to answer their questions.”
Perhaps most tellingly, Sheringer says Julia, a horse lover since babyhood, has a clear sense of pride in herself that wasn’t there before. “She sits up straight on the horse and smiles,” she says, “and especially with autism, it’s really hard to get your child to smile.”
In MaCayla’s case, her weekly hour at TherAplay is just one of several types of therapies she does each week. Cathy Smith, herself a physical therapist, reinforces all the exercises at home. The comprehensive approach means it is difficult to pinpoint exactly which strides are due to the hippotherapy sessions, according to MaCayla’s pediatrician, Dr. Baron Kidd. But one thing is clear: She has made enormous progress in all areas.
Kidd says that hippotherapy “has had a very positive result in her situation. She has definitely progressed.” While she is the only patient in his practice currently using this unique form of physical therapy, he says that after seeing the results in MaCayla, he would refer others.
Pediatric physical therapist Tricia Seddon, who referred the Smiths to TherAplay and still works with MaCayla, says, “I think all the combinations of all the therapies combined, plus the wonderful support of her family, have allowed MaCayla to achieve more than we would typically expect.”
Seddon recalls that initially MaCayla’s trunk strength was so poor that she could not stand straight. “She would stand bent over,” Seddon says. “Once we saw some hippotherapy incorporated, she was more upright, and she had better stomach control.
“Now that she’s more independent, she’s a happier child. Every child gets happier when they start walking,” she says.
A toddler starts over
While Down’s Syndrome meant MaCayla’s parents were prepared to expect developmental delays, expectations were even lower for Mackenzie Alber. As a toddler she contracted bacterial meningitis that severely debilitated her. A mild stroke compounded her issues.
Previously a typically developing child, she now faces challenges on all fronts. “She was a 16-month-old who had to learn how to develop all over again,” her mother, Charity Alber, says. She even lost the ability to swallow; for nine months after her illness she was on a feeding tube.
Alber and husband, Matt, were told Mackenzie would probably never be able to walk, at least not without a cane or walker.
A month after starting hippotherapy at TherAplay, the child took her first independent step. She was 3 years old. Now 8, she has developed the muscle control for saddle riding — enormous progress from the early days when she could not sit up on the horse’s back. “She is learning to guide a horse with her own two hands,” her mother reports with pride and a touch of wonder.
Mackenzie’s confidence has skyrocketed, and this plays out in social interactions as well. Once an isolated child except for the company of her twin Madison, she now socializes with other kids.
She’s learning to put letters together and read small words — breaking another limitation set on her by the experts. TherAplay has had a hand in this; letters are posted around the barn and Mackenzie’s therapist incorporates letter recognition into the sessions.
She’s also been working on life skills like dressing herself and going to the bathroom by herself. This is where the half-hour clinical setting has proved essential. “Dexterity-wise it’s just so hard for her,” her mother says. “She doesn’t have the strength. At TherAplay they have oversized clothes and she can practice putting on shirts and shoes.”
Best of all, she’s starting to progress from walking to running, which is thrilling for her parents to see.
Real world goals
As for MaCayla, she is turning into a “real go-getter” according to her mother — with a stubborn streak a mile wide. “Even though MaCayla’s a Down’s Syndrome kid and she has some delays, she’s not delayed on stubbornness,” Smith jokes. She marvels at Grillo’s knack for keeping MaCayla on track. The therapist doesn’t let her get away with much, but keeps the sessions light, even in the horseless half hour.
Earlier, for example, when MaCayla was sitting on “the big peanut,” Grillo asked her to fall back and then pull herself up. It’s really a sit-up, but the little girl doesn’t need to know that. She’s just having fun.
Grillo says that underneath all the games, “MaCayla’s using muscles she didn’t know she had, and developing her balance and coordination.”
The toddler has always been willing to try new things in the clinic with a little encouragement. The screaming that first time? It stopped as soon as the horse took a step. Every time the horse halted, MaCayla would wail again. So Grillo kept the team walking and shifted MaCayla’s positions on the move. Now even standing high on a horse’s back is no big deal.
“At first,” Grillo recalls, “she didn’t want to stand up or go on all fours. She would cry. It was scary. Now she’s up there shakin’ it!”
Though standing on a horse is an impressive feat, it is not in itself an objective of hippotherapy. Actually, hippotherapy’s therapeutic goals are not remotely horse-related, according to Lori Garone. She’s the program director for the National Center for Equine Facilitated Therapy, and also serves as AHA board member and instructor.
Indeed, the objectives have little to do with horseback riding; they are simply facilitated by the horse. “The goal is not to sit up on a horse,” Garone says. “It’s postural control when the child is sitting at dinner. It’s throwing a ball with their peers. It’s reaching for a toy and not losing their balance.”
In other words, it’s kid stuff. Life stuff. Things most people take for granted.
What’s special about hippotherapy? The answer is evident from the look on the patients’ faces. Therapy? Who’s getting therapy? Who’s a patient? I’m a kid having a pony ride.
Less obvious but critical is the quality of movement. A rider seated on a walking horse will experience the same kind of three-dimensional pelvis movements as if she were walking on her own volition.
More than half of the kids coming to TherAplay for physical therapy have cerebral palsy and have never walked before. For these children, hippotherapy provides the brain’s first input into what it feels like to walk.
At the same time, sitting astride a horse — particularly Gideon, a wide horse — helps ease the tightness in a child’s legs, a common issue with cerebral palsy. Over the course of a ride, the muscles begin to stretch and lose some of their tautness.
“The movement and sensory input you get from a horse is tough to reproduce with equipment,” AHA past president and instructor Bonnie Cunningham says. “You can have consistent repetition for 30 minutes where the therapist would fatigue.”
To the layperson, it seems surprising that such movement ties into so many body systems. For example, it is not uncommon for speech to be among a child’s improvements after hippotherapy is added to her therapeutic regimen.
Garone explains that improved abdominal strength — a benefit of hippotherapy — enables improvements in posture and respiration, which in turn allow for sound formation. Simultaneously, the session addresses any sensory issues so that the child can focus cognitively, setting up a basis for speech. “We get decreased drooling and increased babbling, and it happens because of the movement. Then we can work on formation of words, then one- to three-word sentences to facilitate language,” Garone says.
Curiously, the three-dimensional movement of the pelvis is the same as the three-dimensional movement of the mouth, according to Garone. She quotes a neurodevelopmental specialist as saying, “What begins at the hips comes out at the lips.”
Speech therapist Jennifer Kortepeter, one of the many specialists working with MaCayla, confirms the language benefits of hippotherapy. She says, “One of the things we’ve noticed lately with MaCayla is that her [speech] volume has increased. I’ve seen some lovely gains and I would definitely give credit to hippotherapy in terms of trunk support and strengthening to produce speech.”
A positive environment
Clinical objectives aside, there’s no beating the fact that kids and horses just click.
“The horse is a tremendous motivator,” Cunningham says. “I can’t think of any equipment that motivates as much as the horse does.”
Garone agrees, “These kids get therapy from the time they’re born. When they see a therapist they run away. They don’t run away from a horse.”
Mackenzie’s mother, Charity Alber, says she thought her daughter would be scared of horses, but there was no sign of fear in the then 3-year-old. “TherAplay has done a lot of really good things for her. I adore it because of the way the therapists treat the kids,” she says. “The whole demeanor of the place is just such a positive environment. These kids get enough crud in the world. They feel special when they come here.”
She’s not just talking about the therapeutic staff: Everyone involved seems to have a way with kids, from the behind-the-scenes office staff to the horse handlers.
As if in witness to this, the small powerhouse that is MaCayla, her session over, promptly motors right into the office to say hello. After getting a lift from Grillo to dismount Percy, she has walked unaided in the deep sand of the barn floor — all the way from the far end of the barn to the clinic door. Her wispy blond hair is plastered to her head in places from the knit cap she wears under her riding helmet.
Grillo sums up the day’s work for Bill and Cathy Smith while their daughter explores. She tells them that MaCayla has made progress in leaps and bounds; she shows no sign of leveling off. She asks if they plan to continue. They do, despite some looming financial uncertainties.
Bill is being deployed to Baghdad, and military insurance does not cover the service. The Smiths are unsure how they are going to pay for MaCayla’s continuing hippotherapy. For now, they’re going on faith that the cost will be covered somehow.
According to Ravinet, Indiana First Steps, which provides early intervention services to disabled children under the age of 3, reimburses a portion of TherAplay’s hourly fee for eligible children. A sliding scale helps families who are not eligible for First Steps.
The nonprofit organization is dependent on the community for help. “We need to fundraise $60 per child per hour,” she says. “We need a quarter of a million dollars a year just to keep our doors open.” Events like a recent Golf Championship and an upcoming Hoedown and Wild West Casino on Sept. 15 help defray the costs.
Corporate events help too. Mackenzie’s aunt, Kelli Werner, has a special place in her heart for TherAplay, having seen firsthand how her niece has progressed over the years. She works for the Indiana Housing and Community Development Authority, where she is on the planning committee for a golf outing that will benefit TherAplay. Mackenzie will be the guest of honor, helping to kick off the event with a ceremonial putt.
Innocent of such grownup concerns as funding, kids like MaCayla, Mackenzie and Julia experience some priceless gains through TherAplay’s work.
Cathy Smith marvels, “Since last October to this spring, we’ve gone from a baby that was crawling and rolling to a child that’s practically running.” While the couple was understandably concerned for MaCayla’s future when they first learned of her disability, now they have no doubt that she will be fine.
“Her world has just blossomed,” Smith says, watching her daughter tear around TherAplay’s offices to offer hugs left and right. “She can do anything. And, man, can she hold her own!”
For more information on Children’s TherAplay Foundation and the Sept. 15 Hoedown and Wild West Casino, visit their Web site at http://childrenstheraplay.org/.
The public is invited to tour the facility from 8 to 9 a.m. the third Thursday of each month (except September and December). To register for the tour, contact Breinne Risner at 317-872-4166 or Breinne.email@example.com.
Hippotherapy or equine-assisted therapy is a physical/occupational/speech therapy treatment strategy that uses equine movement. Therapists use hippotherapy as part of an integrated treatment program to achieve specific functional outcomes.
Therapeutic riding, though it implies therapy, really refers to recreational riding adapted for people with disabilities, according to Lori Garone, National Center for Equine Facilitated Therapy program director and hippotherapy instructor. This type of activity is purely recreational, without a specific therapeutic objective.
Garone and others in the hippotherapy field find the latter term misleading. They prefer the term adaptive riding to distinguish from equine-assisted therapy, which is done under the guidance of a therapist with a treatment plan. TherAplay executive director Raquel Ravinet explains, “It really takes a therapist’s eye to know how to use the horse to make a functional difference.”
Other hippotherapy facilities in Indiana
A second equine therapy center located near Indianapolis is the Agapé Therapeutic Riding Center. The horse-assisted programs here offer children with special needs a chance to thrive. Inside a barn at Agapé, a banner reads, “Your I Will is more important than your I.Q.”
Agapé Therapeutic Riding Center
24950 Mt. Pleasant Road
Cicero, IN 46034
Adopt-a-Horse Program: monetary donations needed to support Agapés horses
Agapé Wish List: supplies needed for the facility range from stamps to horse feed
Volunteering: applications can be found on the Web site
North American Riding for the Handicapped Association
NARHA Centers in Indiana